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1、实验动物福利伦理审查表Application Format for Ethical Approval for Research Involving Animals课题名称及编号Program and No.课题来源Sponsor课题负责人Name of Principal Investigator科室Department动物试验负责人Contact Person电话和信箱Contact Tel.No.and Email课题实施动物实验的人数Number of Implement经专业培训的人数Number of certificate参与动物实验操作人员姓名、相关专业证书编号，经验、培训、资质
2、和能力的描述Name and certificate number,Description of experience/training/competency of the individuals carring out the research.动物实验设施许可证编号Name and certificate number of the facility特殊实验设施许可证编号Name and certificate number of the facility申请日期： 年 月 日 受理编号： 批准文号：Appl.Date Y M D Appl.No.IACUC Issue No.现有动物实验
3、设施条件是否与拟开展动物实验的规范性要求相匹配的描述Conformity of facility condition and proposed to carry out experiment requirement拟实验时间：年月日至年月日Experimental period：YMDtoYMD拟 使 用 动 物 信 息Anim动物来源Animal origin 许可证编号Certificate number质量合格证Certification of fitness有无品种/品系Breed/strain大鼠rat：小鼠 mice：裸鼠 nude mice：兔 rabbit：犬 dog：灵长类
4、primary animal：转基因动物 genetically modified animal：其他（具体说明）other：等级Grade普通CV清洁CLSPFGF其他al to be used数量只4&）Number （卡$）体重gWeightg日龄DAgeday周龄WAgeweek月龄MAgemoth选择实验动物种类和数量的原因Reasons for the choice of special and numbers of animals to be used.Detai详细列出对动物可能造成的所有可预期的伤害，包括动物运输、每个实验方案动物饲养方式、实 验操作步骤中等可能产生伤害或不适
5、的细节及拟米取的防控措施Description of the overall harms expected to be experienced by the animals-including details of the likely adverse effects of each protocol, cage breeding and the steps which will be taken to control these adverse effects oled information of the experiments on animals主要观察指标Main observati
6、on targetDetai仁慈终点或实验终结的指标Humance endpoint or experimental terminative indicatorled information of the experiments on animals动物处死方法Death conduct非处死动物的处置方法Not for the death of the animal disposition继续使用Continue to use保存的机构Save in the agency放生野外Release to the wild其他，详细说明Others， detailed descriptionDet
7、ai动物替代、减少动物用量、降到动物痛苦伤害的主要措施Major measure for 3Rsled information of the experiments on animals是否使用有毒（害）物质（感染、放射、化学毒、其他）Poisonous （harmful）material （infection， radiate， chemical poison and other）being used 否no是 yes说明：Declare利害分析的小结，说明为何预期的利益多于害处？A summary of the harm-benefit analysis - why the expecte
8、d benefits might be considered to outweigh the predicated harms?相关的补充说明或辅助证明文件Supplementary instruction or any auxiliary documents for investigate信息公开和保密要求：说明哪些信息需要保密，哪些信息可以公开Declaration for the information disclosure and confidentiality requirements， declaring the information need to be kept secret
9、， the information can be disclosed。对伦理委员有无回避要求Claiming jurors for being debarb。声明：1我将自觉遵守实验动物福利伦理相关法规和各项规定，同意接受伦理委员会和实验动物室管理者的监督与检查。2.本人保证本申请表中所填内容真实、详尽和易懂。Declaration： 1.I will abide by the law and regulation stipulation， and accept the supervision and inspection by thecommittee and laboratory anim
10、al department。2.The information I have given is accurate， detail and comprehensive。声明人：课题负责人签（章）Declarant： Signature （stamp）of PI动物实验负责人签（章）Signature （stamp）of Director of animal experiment 年月日YMD申报部门意见Opinion of application Department of institution研究室负责人签(章)：Signature (stamp) of the Department pri
11、ncipal 年月 日YMD主管医师意见Opinion of Veterinary of institution主管医师签(章)：Signature (stamp) of Veterinary实验动物设施意见Opinion from laboratory animal facility福利伦理委员会审批意见Approval pinion of Committee审查委员会表决：Inspection by menbers： Agree (设施负责人签(章)：Signature (stamp) of the facility Director)；Disagree ()主任委员签(章)：Signature (stamp) of Chirman of Committee 年月 日YMD备注：初审； 第 次审查。Remarks first trial； reexamine No.申报说明：申报时，请提交本表一式两份及电子版。受理文号和批准文号由伦理委员会填写。Notice:Submitting the Application Format in duplicate and a electronic edition. The Appl.No. are make out by Jury.
